The bottom up NHS will only work if the middle gets the message

"Bottom up" is an important concept with an unfortunate lack of decent synonyms. "Grass roots" is hackneyed, while "organic" doesn't really convey a sense of the direction of change, and "ground up" could easily be confused with something that had just been pulverised.

You can bet this was all hotly debated by earnest teams of professional communicators before the publication of the white paper, but that's because these things matter.

It takes just three paragraphs of the foreword by David Cameron, Nick Clegg and Andrew Lansley to mention "excessive bureaucracy and top-down control" and only another four before we learn that from now on "healthcare will be run from the bottom up".

The white paper goes on to say that "implementation will happen bottom up" and a few pages later we learn that change will happen that way too.

There may be accidents as a result of white papers but there are no accidents in them. The choice of words is made with great care. Once the words have been chosen they will be flogged to within an inch of their lives. Repetition and consistency of message are critical factors in government communications.

The Bellman in Lewis Carroll's Hunting of the Snark says: "What I tell you three times is true". Public sector spin doctors and speech writers play it safe by telling you three times a minute.

Sir David Nicholson has made several speeches in which the bottom-up message has been driven home forcefully. Sir David is a straightforward man and an unlikely civil servant. It is difficult to imagine him spinning.

So when he acknowledges that previous attempts to devolve power lacked conviction and insists that this time the government means it, it's tempting to believe him.

If top-down control was the hidden agenda, then it wouldn't make sense to do it this way. There are easier ways to restructure institutions and cut management costs.

The reason bottom-up change is so important is because there is no other way GP commissioning can work.

If change does not start with individual practices then none of the patient centred benefits envisaged by the policy will happen. Change at practice level is the key to achieving both quality and productivity gains, because until individual clinicians feel not just a vague sense of responsibility for the decisions they make in their surgeries but are accountable for the consequences, any attempt to impose change will have at best a marginal impact on the system.

This is why for all the government's desire to keep GP commissioning on track for implementation within two and a half years it keeps issuing warnings against forming consortia too fast. It is worried about the wrong kind of consortia, formed around PCT boundaries, serving the same populations, led by the same people, doing the same things. Formed, in other words, around the belief that the last thing the NHS should do is devolve power to clinicians.

The real fear is not that the bottom-up NHS will be defeated by a government unable to control its top-down urges, but that if the middle of the system fails to get the message GP commissioning will be strangled at birth.